Healthcare Provider Details

I. General information

NPI: 1053479980
Provider Name (Legal Business Name): JAN K BRYDON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W 24TH ST STE 305
ERIE PA
16502-2666
US

IV. Provider business mailing address

311 W 24TH ST STE 305
ERIE PA
16502-2666
US

V. Phone/Fax

Practice location:
  • Phone: 814-454-4484
  • Fax:
Mailing address:
  • Phone: 814-454-4484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD029742E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: